Physicians at War: Moral Injury

A physician’s job is hard. They are on the battlefield fighting to make this world a healthier place. Every day, they sacrifice their time and energy. This sacrifice can lead to burnout.

In a recent blog, we highlighted how administrative burden is a large contributor to physician burnout. A lot of money and time is spent on reporting on external quality measures. But there’s more.

Dr. Keith Corl argues that there is something deeper— a sense of “moral injury.”

What is moral injury, you ask?

The term “moral injury” comes from war, to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder.

Veteran hospital researchers say that it refers to “the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Bottom line, it’s not a good feeling.

Moral Injury in Las Vegas

A patient complaining of chest pains walks into a Las Vegas emergency room. Triage consisted of a two minute exam, an x-ray and many other tests. Dr. Keith Corl finally meets the man and lifts his shirt. And guess what? Lo and behold, the patient had shingles. Dr. Corl didn’t need any tests to diagnose this painful viral infection.

So, all those tests? – a waste of time and money. The patient was left with more than $1,000 in extra charges. That’s money they can’t get back.

How does this happen?

According to Dr. Corl, there is a model of emergency care that forces doctors to practice “fast and loose medicine.” Fast and loose means just what you think it means. Patients receive a bunch of rapid tests before a proper exam.

Doctors are taking shots in the dark instead of just examining and listening to the patient.

It’s taking a toll on the patient and the doctor. Dr. Corl and other physicians, nurses, social workers and other clinicians are using the phrase “moral injury” to describe their inner struggles at work.

Beginning Talks of Moral Injury

When you know better, you do better. Well, you should want to.

That’s all Drs. Wendy Dean and Simon Talbot want to do. They know how to best care for their patients but can’t do it because of certain barriers related to the business side of health care. And it’s frustrating. Moral injury was the only word that came to mind to fully describe the frustration and burnout.

Their eye-opening op-ed touched the hearts of clinicians across the country and led to many emails, calls and speaking engagements. Finally, someone was speaking their language.

Emergency Medicine, What Doesn’t Work

Have you heard of “provider-in-triage”?

It is a model of emergency medicine that prioritizes speed over quality care. There is a two-minute triage visit with numerous tests to follow. And the tests are sometimes pointless.

This is what happened with Dr. Corl in Las Vegas.

Sure, the brief encounters may be good for business because they reduce how long it takes to see a doctor. And they reduce the number of people who leave the ER without being seen. But hospitals can charge a facility fee much earlier. This means the more patients seen, the more money.

With the real priority being speed and money and not a patients’ care, doctors feel burdened.

“That makes it tough for doctors who know they could be doing better for their patients.”

Dr. Dean explains that clinicians often frame burnout as a personal failing. While others may think it’s as simple as a doctor needing a little “me-time”, it’s way more complicated than that. Burnout is related to systemic problems beyond a clinicians’ control.

So, what now?

A Hope for Change

Unfortunately, some people are leaving the health profession. Clinicians are feeling a sense of anguish that they haven’t felt in the past.

Dr. Dean stopped treating patients as a psychiatrist because of financial pressure. She knew her patients needed longer visits and medication management. But insurers only wanted to pay her for 15-minute sessions to manage medication.

 “The health system is not set up to help patients. It’s set up to make money.”

Dr. Col moved to smaller community hospitals to escape the provider-in-triage method. The system just wasn’t working. He explains that “moral injury” speaks to the flaws in the health care system and how that system is pushing away good doctors.

But there is hope.

Drs. Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, to promote public awareness and bring clinicians together to continue the dialogue around moral injury. And it’s a big hit among doctors and other clinicians.

Hopefully the future generations of doctors can learn something from the experiences of those who came before them. Hopefully they can find out a way to win the war against physician burnout.

Did you know that 4 in 10 physicians report feelings of burnout? Not to mention that the physician suicide rate is more than double that of the general population.

It’s a sad situation.

So, what is moral injury? It’s feeling like you can’t do the right thing. It’s a feeling that is running good doctors away.